Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Worst test question ever! – Maybe

 

Thank you to David Baumrind of EMS 12 Lead for linking to this here. It probably is not the worst test question ever, but it is very bad.

Read the question, figure out what your response would be, then scroll down for my explanation.
 

You are dispatched emergency traffic to the scene of a 24 yo F with “palpitations.” You arrive to find her pale, sweaty and lethargic. You palpate a radial pulse with an extreme rate. You hook her up to the monitor and find the following rhythm? You have a 45 minute transport time. Which of the following is the most appropriate initial treatment for this condition?

1.) Nitroglycerin 0.4mg SL
2.) Immediate synchronized cardioversion
3.) Adenosine 12mg Rapid IV push followed by 20cc NS bolus
4.) Epinephrine 1mg 1:10000 q-3-5m IVP

-Admin Paul

The original posting was from Exhausted Medic Students ‘R’ Us here.

Go read the original with its hundreds of comments.

 

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All of the answers are completely wrong.
 

ST (Sinus Tachycardia) is the rhythm.

There are clear P waves with consistent PR intervals. It is faster than what some people expect to see from ST, but that is because many of us do not think about what we are learning in EMS.

It is true that the cardiology part of paramedic school is probably the toughest for most people, and we are overwhelmed with new information, but we should be very familiar with this rhythm.

Carry a patient up/down a flight of steps and you may have significant ST – maybe even faster than what is on this strip. If your heart rate is over 150, so what?

Before you have a chance to recover, use the pulse oximeter to measure your heart rate after carrying a patient. You are just checking the accuracy of the machine before applying it to the patient, or before reconnecting it to the patient.
 

1. Nitroglycerin is NOT indicated for palpitations.

NTG is not indicated even for a lot of palpitations. Do you have a protocol for NTG for palpitations?

Ask your medical director how much NTG should be given for palpitations, but don’t be surprised if you are expected to go through some scenarios to demonstrate that you would not really give NTG for palpitations.
 

2. Cardioversion is NOT indicated for sinus tachycardia.

Cardioversion is supposed to cause asystole. During that asystole, it is hoped that the sinus node will become the pacemaker for the patient’s rhythm.

SINUS tachycardia means that the sinus node is already the pacemaker.
 

Cardioversion of sinus tachycardia can only make things worse.
 

Cardioversion of sinus bradycardia can only make things worse.

Cardioversion of any sinus rhythm can only make things worse.
 

3. Adenosine is NOT indicated for sinus tachycardia.

The dose does not matter. The drug is not indicated.

No matter how wrong NTG is for palpitations, adenosine is worse.
 

4. Epinephrine is NOT indicated for sinus tachycardia with a pulse.

How much faster do we want this ST to be? Epinephrine can make it faster.
 

Maybe some people think that the choices should include a vagal maneuver.

No. That would also be wrong.

Calcium channel blocker?

Another wrong.

Beta blocker?

Wrong again.
 

No competent paramedic should attempt to justify any of these answers.

Maybe this is a question to find out just how incompetent people will be to satisfy an authority figure.

One horrible answer is –
 

As a paramedic instructor and a evaluator for National Registry…if my student didn’t cardiovert…I’m failing them.

 

Does the National Registry hire people this ignorant as evaluators?

Yes, but so does every other testing organization. Maybe this guy is lying about being an instructor and evaluator, but this is EMS and we like low standards.

A defender of cardioversion posted the ACLS tachycardia cheat sheet.
 

Click on image to make it larger.

 

Unfortunately, the cheat sheet does not state that we should not shock sinus tachycardia.

If all we know is the cheat sheet, we should consider a career change to explore the exciting world of fast food order fulfillment.

The text of the 2010 ACLS guidelines states –
 

ACLS professionals should be able to recognize and differentiate between sinus tachycardia, narrow-complex supraventricular tachycardia (SVT), and wide-complex tachycardia.[1]

 

A lot of people could not recognize an obvious sinus tachycardia.

Is that the fault of their instructors?

Yes and No.
 

Sinus tachycardia is among the rhythms listed that we are expected to be able to identify.
 

Synchronized cardioversion is recommended to treat (1) unstable SVT, (2) unstable atrial fibrillation, (3) unstable atrial flutter, and (4) unstable monomorphic (regular) VT. Shock can terminate these tachyarrhythmias by interrupting the underlying reentrant pathway that is responsible for them.[1]

 

Sinus tachycardia is not listed among the rhythms that should be shocked.

Here is the important part –
 

If judged to be sinus tachycardia, no specific drug treatment is required. Instead, therapy is directed toward identification and treatment of the underlying cause. When cardiac function is poor, cardiac output can be dependent on a rapid heart rate. In such compensatory tachycardias, stroke volume is limited, so “normalizing” the heart rate can be detrimental.[1]

 

We treat sinus tachycardia by treating the cause.

The cause of sinus tachycardia is never lack of cardioversion.
 

A good test near the end of the cardiology section of paramedic school might include this question to find out if the students have learned anything.

All of the choices are wrong.
 

In medicine, there is not one best answer for all patients.
 

Anyone who says differently is selling something.

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Footnotes:

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[1] Tachycardia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Cardioversion and Regular Narrow-Complex Tachycardia

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Comments

  1. That truly is the worst test question I’ve ever seen and you explained why sinus tach should not be cardioverted very well. Thank you!

  2. My favorite were the folks who arrived at the conclusion that this was not SVT through yet another half truth/trick: “SVT has no P-waves!”

    Invariably we had folks chime back in, again due to knowledge of half truths/tricks, that: “yes, SVT can have P-waves! Thus, this is SVT! QED.”

    (we’ll temporarily ignore that SVT is not actually a rhythm)

    Sigh.

    I don’t know which is worse…wrongly arriving at the right conclusion or rightly arriving at the wrong conclusion……..

  3. This looks like a question the NYC REMAC committee would put on their poorly written tests

  4. Facepalm.

    Similarly disappointing clinical reasoning was on display recently on EMSDoc911′s FB page, in response to a case study he posted.

  5. I have been a long time follower of your site as well as countless others. I have recently discovered the exhausted medic student facebook site and thus far enjoyed the conversations on their site. One thing I can say is that their site has been designed and geared towards Paramedic students to gain insight into their learning through interaction with others. Most conversations have been productive, but this one turned nasty. Instead of having competent EMS providers give advice to the posters who were mostly students I witnessed several instead ridicule them and this was disheartening. The original post and question is direct from an NREMT test bank asking you to pick the most appropriate answer out of the 4. While the entire scenario, ECG presented for the scenario and answers are obviously askew they attempted to give their most appropriate answer. Then something happened, exactly what the NREMT wants to happen, people began to over think the entire scenario and got creative with their answers. The problem is on the NREMT test there is no chance to do that, you simply pick whats best. The NREMT test expects the student to pick cardioversion on the basis that the patient has a narrow complex unstable tachycardia. Again its what the NREMT expects out of this question and sadly it is what medic students are taught and needs to be changed. Their are programs out there that teach to the minimum standard and until we become a nationally equivalent competency you’ll continue to see this. Many paramedic students desire to learn only whats necessary to pass the course and get by. Many others read the entire ACLS book and maybe learn something, then they leave class and continue to learn. You are clearly among that category who will not accept the minimum and I applaud you for your attempt to clarify this scenario. This was linked to their page and hopefully some of the students read this blog. I just wish you could have explained it better on their page with out the ridicule of others and the need for you to defend your thoughts outweighing the logic.

    • NREMT-P does not expect students to cardiovert sinus tachycardia…ever. It became a losing battle explaining what sinus tachycardia is and why SVT is not defined by rate.

      • Additionally, i do not believe in the “test mentality” vs the “street mentality”. I am an educator, and from what I have seen, folks play how they practice. If they “learn” to cardiovert ST in class, that is what they will do on the street. It is happening.

    • While I understand the concept of the whole “pick the BEST answer of the choices given” process, it doesn’t work in this situation. Rather than presenting four possible answers, of which three are not necessarily *wrong* but one is more appropriate or a higher priority than the others, this particular question present a scenario and four possible answers which are all contraindicated. There isn’t a “best” answer here … They are all likely to harm the patient.

  6. I don’t think any “ridicule” was directed towards the students….it was directed at those who should know better.

  7. Uh, yeah…

    I know this is a “test question”, but hell, it’s flu season. I’ve seen plenty of younger, otherwise healthy adults present the same way.

    If you feel the need to initiate ALS care (and the question leaves out a lot of things I’d like to know), the best (non-existent) choice would be to start a line and give a little fluid. But no….some people want to light ‘em up. Go figure.

  8. Why can’t the rhythm in question be considered Atrial Flutter with 2:1 conduction?

  9. The problem is this, and I just went back to my Cardiac Text Book for this one. The textbook definition is a rate OVER 150 with a narrow complex is SVT. The textbook says this patient is presenting as unstable and needs Medicine by Edison. The problem is I may get 1 out of every few hundred patients that read the textbook…

    Cardiology textbooks do not think and are black and white. I smack students that say “the texbook says” or “the textbook answer is”. If I wanted that I would have read it and not asked. I understand why the students are missing this and I understand why there is an arguement. CLEARLY this is Sinus Tach and not a big deal, hell maybe she just had some great sex and needs a smoke, not a shock or poisoned…Point is without a full hx as to what lead up to this episode you have no idea what to do.

    • The textbook definition is a rate OVER 150 with a narrow complex is SVT. The textbook says this patient is presenting as unstable and needs Medicine by Edison.

      IMHO, that’s a problem with the textbook as well. Rather than encouraging critical thinking, it just gives a blanket definition that can be asked on a multiple choice exam.

      Cardiology textbooks do not think and are black and white. I smack students that say “the texbook says” or “the textbook answer is”. If I wanted that I would have read it and not asked.

      Hopefully, that method of teaching will result in more medics with critical thinking skills and fewer cookbook, blindly-following-protocol paramedics.

  10. Rogue Medic,

    Although I agree this is a horrible question, I do not completely agree with your assessment of the rhythm. Additional information is needed, is the patients rate steady or varying with movement or positioning? What is the patient history? Is this a sudden onset or progression of symptoms until EMS activation over days or weeks. If the HR is dead on, say 165bpm, and doesn’t vary then I believe that we have a rate problem! If the history includes a history of progressive illness and poor intake or symptoms of bleeding or dehydration then fluid bolus is appropriate with dehydration or hypovolemia. However, by definition a HR over 150pbm in an adult without a history is atrial tachycardia until proven otherwise.

    I think your points are generally appropriate, but lets not forget that sometime the history makes the case! Either way ,I don’t like any of the offered answers either!

    Brian Bates, NREMT-P, RN, CEN

    • That is not the correct definition of atrial tachycardia. Atrial tachycardias range in rate from 100-220ish depending on when you believe it constitutes Atrial flutter.

      150 has no special significance. In fact, SVT can range in rate from 80-260+!

      Wait, did I just say tachycardia with a rate less than 100?! Too crazy…err nevermind tachycardia is a relative term and junctional ectopic tachycardia (aka JET aka FJT aka JT) doesn’t have to be 100+ to be called a tachycardia.

      So pleaaase stop spreading this 150 bpm misinformation, it does nobody any good.

  11. Questions like these are the exact reason I have failed the nremt-p written exam twice. Despite finishing my program with good grades and having a very successful clinical trials. I feel as though more then half of my questions have had no right answer and two answers that are almost the best choices, but still wrong. Help please

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